Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Covenant Shores Health Center during CMS and state inspections, most recent first.
The facility failed to provide required written notices to residents and their representatives during hospital transfers, as per their policy. This deficiency was noted for three residents who were transferred multiple times with anticipated returns. The facility's Administrator and DON confirmed the lack of a process for issuing these notices.
The facility failed to accurately complete PASRR assessments for three residents, omitting key mental health diagnoses such as depression and anxiety. This oversight was confirmed by a social worker who acknowledged the need for correction to ensure residents' needs were met.
The facility failed to obtain informed consent for the use of a Tilt-in-Space wheelchair for two residents with severe memory impairments. Both residents were observed using the wheelchair without documentation of informed consent, which was acknowledged as necessary by the DON.
A facility failed to assess a resident's ability to self-administer medications, including an inhaler, ointment, and nasal spray, which were found on the resident's bedside table without proper authorization. The MAR only authorized the inhaler to be kept at the bedside, and there was no assessment in the medical record to ensure the resident could self-administer these medications. Interviews revealed the resident used the inhaler frequently and had not received instructions on medication use. Staff confirmed the lack of physician orders and assessments for the nasal spray and ointment.
The facility failed to maintain Advance Directives (AD) documentation for two residents, one with severe memory impairment and another with intact memory. Despite initial inquiries by a social worker, there was no follow-up to obtain the necessary Durable Power of Attorney (DPOA) paperwork, leaving the facility without critical documentation for healthcare decision-making.
The facility failed to investigate falls and skin injuries for three residents, leading to unresolved causes and inadequate monitoring. A resident with orthostatic hypotension had incomplete neurological checks after falls, while two residents with skin injuries had no root cause identified or documented investigations, despite their medical conditions and communication impairments.
The facility failed to implement comprehensive care plans for residents with complex medical needs, including those requiring supplemental oxygen, restorative programs, diabetes management, edema monitoring, and skin protection. This led to unmet care needs and potential negative health outcomes.
The facility failed to assess the suitability of Tilt-in-Space wheelchairs for two residents with severe memory impairment and mobility issues. Observations showed these residents using the wheelchairs without documented assessments or care plan instructions for their use. Staff interviews indicated that assessments were the responsibility of the therapy department, but no supporting documentation was provided.
The facility failed to secure medications and assess residents' ability to self-administer, as evidenced by observations of three residents with medications left at their bedside without proper assessment or authorization. A resident was found with eye drops and pills unattended, another with prescription ointments and inhalers, and a third with oral anesthetic gel. Staff confirmed that assessments and physician orders were lacking, leading to unsecured medications.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide required written notices to residents and their representatives at the time of transfer to the hospital or as soon as practicable, as mandated by their policy. This deficiency was identified for three residents who were reviewed for hospitalization. The facility's policy, dated October 2022, stipulated that for emergent transfers, a Notice of Transfer should be provided in a form and manner understandable to the resident and their representative. However, the records for Residents 28, 5, and 7 showed no documentation of such notices being provided during their multiple hospital transfers. Resident 28 was transferred to the hospital on July 30, 2024, with an anticipated return, but there was no documentation of a written notice of transfer. Similarly, Resident 7 was transferred to the hospital on four occasions between June and October 2024, and Resident 5 was transferred twice in October and November 2024, all with anticipated returns. In each case, there was no documentation of the required written notices being provided. During an interview, the facility's Administrator and Director of Nursing confirmed the absence of a process for providing written transfer notices to residents and their representatives.
Inaccurate PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Pre-Admission Screening and Resident Review (PASRR) assessments for three residents, which is crucial for identifying mental health or intellectual disability needs. Resident 33, who was admitted with a diagnosis of depression and was receiving antidepressant medication, had a PASRR that did not indicate a serious mental illness, as depression was not marked. This oversight was confirmed by Staff C, the social worker, who acknowledged the need for correction to ensure the resident's needs were met. Similarly, Resident 7, who was also diagnosed with depression and receiving antidepressant medication, had a PASRR that only noted anxiety, omitting the depression diagnosis. Resident 2, with diagnoses of anxiety, depression, and bipolar disorder, was receiving multiple medications for these conditions, yet their PASRR only marked mood disorders and did not include anxiety, nor was a Level II evaluation referral made. Staff C admitted to being unaware of the new regulations requiring such referrals, indicating a gap in compliance with the PASRR process.
Failure to Obtain Informed Consent for Medical Device Use
Penalty
Summary
The facility failed to ensure that residents were provided with informed consent regarding the use of a medical device, specifically a Tilt-in-Space wheelchair, for two residents. Resident 31, who had a history of stroke and severe memory impairment, was observed using a Tilt-in-Space wheelchair without documentation of informed consent from their representative. This wheelchair type could potentially restrain the user as the angle could not be adjusted by the user themselves. Similarly, Resident 26, who was assessed with severe memory impairment and complex medical diagnoses including dementia, was also observed using a Tilt-in-Space wheelchair without any documented informed consent. The Director of Nursing acknowledged that the informed consent process should have been completed, with potential risks and benefits explained prior to the use of such a device. The lack of informed consent documentation for both residents placed them at risk for loss of autonomy.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medications, which included an inhaler, a tube of ointment, and a nasal spray. Observations showed these items on the resident's bedside table without proper authorization or assessment. The Medication Administration Records (MAR) indicated that only the inhaler was authorized to be kept at the bedside, while the nasal spray and ointment were not. There was no documentation in the resident's medical record to confirm that an assessment had been completed to ensure the resident could self-administer these medications according to the physician's instructions. Interviews with the resident and staff revealed that the resident was using the inhaler frequently and kept it on the bedside table for convenience, as they needed it during the night. The resident stated that they had not received instructions or a demonstration on how to use the medications. Staff confirmed that there were no physician orders for the nasal spray and ointment to be kept at the bedside and that the resident had not been assessed for self-administration. The Director of Nursing acknowledged that a self-medication assessment was missing due to a recent change in the medical records system.
Failure to Maintain Advance Directives Documentation
Penalty
Summary
The facility failed to ensure that two residents had the appropriate Advance Directives (AD) in place, which is a requirement to honor residents' rights regarding medical treatment and end-of-life care. For one resident, who had a history of stroke and severe memory impairment, the facility did not have the Durable Power of Attorney (DPOA) paperwork on file, despite the resident's representative indicating they would provide it. The social worker documented the initial inquiry about the AD paperwork but did not follow up to obtain the necessary documents. For another resident with intact memory, the facility also lacked the DPOA paperwork, even though it was noted on the resident's Face Sheet. The social worker recorded a progress note indicating they would contact the resident's relative to obtain the DPOA paperwork, but no further follow-up was documented. Interviews with the residents and the social worker confirmed the absence of the required documentation and the lack of follow-up efforts to secure it.
Failure to Investigate Falls and Skin Injuries
Penalty
Summary
The facility failed to thoroughly investigate a fall incident involving Resident 88, who was at risk for falls due to complex medical conditions including orthostatic hypotension, atrial fibrillation, and a recent urinary tract infection. The investigation into the unwitnessed fall on December 3, 2024, did not consider orthostatic hypotension as a potential risk factor, despite the resident's low blood pressure reading post-fall. Additionally, neurological checks initiated after a subsequent fall on December 6, 2024, were not completed as required, leaving gaps in monitoring the resident's condition. For Resident 23, the facility did not establish a root cause for skin tears discovered on two separate occasions. The investigations into these injuries of unknown origin did not identify how the skin tears occurred, despite the resident's fragile skin condition and severe memory impairment. The lack of a thorough investigation into these incidents left the cause of the injuries unresolved. Resident 33, who had communication difficulties and memory impairment, was found with undated foam bandages on their forearm and shin, indicating skin injuries. The facility failed to document or investigate these injuries, as there were no incident reports or treatment orders in place. Despite the resident's history of falls, the facility did not log any incidents related to the skin injuries, and staff were unaware of any skin treatments, highlighting a lack of proper investigation and documentation.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to unmet care needs and potential negative health outcomes. Resident 5, who had a heart condition requiring supplemental oxygen, did not have a care plan addressing their oxygen use, including goals or instructions for the concentrator settings and care. Staff acknowledged the absence of a care plan despite the resident's need for supplemental oxygen. Resident 31, with a history of stroke and severe memory impairment, was observed with curled fingers and was supposed to be on a restorative nursing program. However, the care plan lacked details on who was responsible for the program and its frequency. Staff were uncertain about the resident's need for the program, and the Director of Rehabilitation confirmed the resident was on a restorative program. Resident 33, diagnosed with diabetes and communication difficulties, had multiple orders for anti-diabetic medications but no care plan addressing diabetes management. There were no instructions for monitoring blood sugar levels or when to notify a physician. Resident 7, with heart and kidney failure, experienced swelling in their feet, but their care plan did not include monitoring or documenting edema. Lastly, Resident 23, with fragile skin, was observed without protective sleeves despite a care plan indicating their necessity to prevent skin tears. Staff confirmed the need for skin protection but failed to ensure compliance with the care plan.
Failure to Assess Suitability of Tilt-in-Space Wheelchairs
Penalty
Summary
The facility failed to complete a formal assessment prior to the use of a Tilt-in-Space wheelchair for two residents, which is a requirement according to the facility's policy. Resident 26, who has severe memory impairment and complex medical diagnoses including dementia, was observed using a Tilt-in-Space wheelchair labeled with another resident's name. There was no documentation showing that the facility assessed the suitability of this wheelchair for Resident 26. The resident's care plan included an intervention to assist with mobility using the Tilt-in-Space wheelchair but lacked any explanation for its necessity or directions for its appropriate use. Similarly, Resident 31, who has a history of stroke and one-side paralysis, was also observed using a Tilt-in-Space wheelchair without any documented assessment of its suitability. The care plan for Resident 31 provided instructions for using the wheelchair for locomotion but did not explain the need for this specific type of wheelchair or include directions for its proper use. Interviews with staff revealed that assessments were supposed to be completed by the therapy department, but no additional documentation was provided to support that these assessments were conducted.
Failure to Secure Medications and Assess Self-Administration
Penalty
Summary
The facility failed to ensure that medications and biologicals were secured, as evidenced by observations of three residents with medications left at their bedside without proper assessment or authorization to self-administer. Resident 14 was observed on two occasions with lubricating eye drops and a medication cup containing pills on their over-the-bed table. Staff G, a registered nurse, confirmed that they were supposed to stay with the resident until the medications were taken but did not do so. There were no assessments or orders in Resident 14's records indicating they were able to self-administer medications. Resident 29 was observed with a tube of prescription ointment, a prescription nasal spray, and a prescription inhaler at their bedside. The resident stated that staff had not assessed their ability to properly use the inhaler. Staff B, the Director of Nursing, confirmed that residents should have physician orders to keep medications at their bedside and that staff should complete an assessment to ensure safe self-administration. Resident 88 was observed with a tube of oral anesthetic gel on their bedside table, which Staff B stated should not have been there. These observations indicate a failure to secure medications and assess residents' ability to self-administer, as required by regulations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mercer Island
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kin On Health Care Center | 3.8 mi | — | 0 | 0 |
| Caroline Kline Galland Home | 4.2 mi | — | 26 | 0 |
| Washington Care Center | 4.2 mi | — | 30 | 0 |
| Transitional Care Of Seattle | 4.3 mi | — | 49 | 0 |
| Park Shore | 4.9 mi | — | 36 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.